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Quick Nutrition Intake Form

Show Us EXACTLY How You Want Us To Help YOU… The more we know about you, the better we can help you…

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Question 1 of 15

What is your best email?

Question 2 of 15

What is your cell phone number?

Question 3 of 15

Please enter your Full Name

Question 4 of 15

How did you hear about us?

A

Amazon (#1 Best Seller Winning Wellness Method)

B

Instagram

C

Facebook

D

Physical Therapist

E

Friend

F

Other

Question 5 of 15

If someone referred you to Winning Wellness & Physical Therapy, please state the name of the person or clinic. Please put "N/A" if no one referred you. 

Question 6 of 15

What’s the primary reason for wanting to speak to a specialized Registered Dietitian?

Question 7 of 15

What is your main problem or concern?

Question 8 of 15

How long have you struggled with this?

A

Haven’t- This is prevention (not cure)

B

Days

C

Weeks

D

Months

E

Too long (years)

Question 9 of 15

What’s your greatest worry about your current situation?

Question 10 of 15

What are your current goals?

Question 11 of 15

How committed are you to achieving those goals?

A

Not committed

B

A little committed

C

Very committed

Question 12 of 15

Where would you want your health and weight to be in the next 6 to 12 months?

Question 13 of 15

Who Do You Prefer To Work With As Your Nutrition Coach?

(Select all that apply)
A

Dan Feldman

B

Melissa Bushnell

C

Sarah Czarnecki

D

No Preference

Question 14 of 15

What made you apply today of all days? Is there anything else that we should know?

Question 15 of 15

I understand that in order for me to get results I must take action and COMMIT to the process. I understand that this is a SUCCESSFUL process, but a process nonetheless. 

A

Yes, I understand.

B

No, I am not willing to commit.

Confirm and Submit